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2. This form is available for businesses to use under the City’s voluntary disclosure program. The form is not mandatory. A letter may be submitted in place of this form. Business should also include the following information:
   • Schedules (by year) showing gross income generated in Everett by classification along with any deductions; and, • Taxpayer Authorized Representative Declaration if the business is represented by a third party
4. Business Name
6. Legal*
8. Trade (doing business as):
10. Physical Address
12. Address1*
14. Address2
16. City*
17. State*
18. Zip*
20. Mailing Address
22. Address1*
24. Address2
26. City*
27. State*
28. Zip*
30. Contact Information
32. First Name*
33. Last Name*
35. Title*
37. Phone Number*
39. Email Address*
41. Are you being represented by a third party? *
    -- Select One --YesNo

    If yes, please provide a completed Taxpayer Authorized Representative Declaration with this application, available under Additional Tax Forms
42. Have you previously been contacted by the City?*
    -- Select One --YesNo
44. Have you engaged in evasion or misrepresentation?*
    -- Select One --YesNo
45. Is the business currently under audit by the City of Everett?*
    -- Select One --YesNo
47. Have you ever been issued a City of Everett business license?*
    -- Select One --YesNo
49. Description of Business Activities*
51. How did you establish nexus with the City?*
53. Date of the first business activity in Everett*
    Date of the first business activity in Everett
55. Additional notes
57. I certify that all of the above information is true to the best of my knowledge
    Please enter the information below to certify and submit your application for voluntary disclosure.
59. First Name*
60. Last Name*
62. Date*
    Date
63. Title*
65. Phone Number*
66. Email Address*
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field